Individual
DR. JOHN MICHAEL HAUTALA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1033 REGENTS BLVD, SUITE 102, FIRCREST, WA 98466-6045
(253) 564-1115
(253) 565-4552
Mailing address
1033 REGENTS BLVD, SUITE 102, FIRCREST, WA 98466-6045
(253) 564-1115
(253) 565-4552
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
MD00019059
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
108917
L&I NUMBER
WA
05
—
1783703
—
WA
01
—
HA7840
REGENCE BLUE SHIELD
WA
01
—
MD00019059
STATE LICENSE NUMBER
WA
Enumeration date
02/10/2007
Last updated
03/07/2023
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